“Fears, joys and struggles.” An Interview with Anne Jacobson

Anne Jacobson is a family physician with a master’s in Public Health. Her work has appeared in JAMA. She lives with her husband and two children in Chicago. Her essay “To Morning” describes a difficult night late in her residency—three codes, three deaths: one young woman with a sudden illness, an older man with no family present, and a woman whose grief-stricken husband is by her side. Interview conducted by Robyn Jodlowski.

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We receive lots of stories about untimely or particularly sad deaths. Does writing give you some form relief from remembering patients like the 20-year-old woman, Tamara, who died so suddenly?

Writing definitely helps me to process not just big events, like a patient dying, but also day-to-day interactions that take place in the office. Sharing in people’s fears, joys and struggles is such a privilege, but paying attention to that is often really difficult in the course of a harried and busy day. I try to keep a journal of stories and reflections on one or two patients that I see each day, and I find that it helps me to pay attention in a completely different way. And certainly when there is a particularly stressful or sad event, writing is an important outlet. I had been trying to find a way to put the story of that particular night on call into words for a long time.

The phrase you use about your patients—“trying to die”—really hit me as a different way of thinking about dying. It’s like you’re separating the will of our bodies from the will of our minds. Or almost like your patients become their own antagonists. How do you see that split?

The split represented by that phrase was more about the way people like the elderly man in the essay are ready to go: it is their time, their bodies and spirits are worn out—but someone else on the outside is not ready to let that happen. Sometimes that outside force is the medical establishment. Sometimes it is one or more family members that are not ready to give up all efforts to keep someone alive. And sometimes, yes, it is the person himself. The mind and body have such an effect on each other, often on a subconscious level, that it is sometimes difficult to know why or how someone is still alive when they seem to be “trying to die.”

What advice do you have for current and future residents in dealing with death on the job?

Take time to process it. Some residency programs have formal programs with group sessions that help residents to process difficult events, and that can provide an enormous support for some people. Others may find it easier to rely on one or two close individuals. For others, writing is the outlet, or running it out, or keeping grounded in some other non-medical pursuit. It’s also important to remember the 100% death statistic. Sometimes the measure of success is not how long you kept someone alive, but how you participated in affecting the quality of his or her life.

After reading your essay, I couldn’t help but think how hopeful doctors, and really the medical professions as a whole, are. Everyone’s going to die, but everyone wants to prohibit it. How do you summon hope amidst the 100% statistic?

In general, medical professionals are perfectionists. We have high, sometimes unreasonable, expectations of ourselves and of our profession. This trait is useful when it drives medical advancements to improve health or decrease suffering, or pushes us individually to pay attention to important details. It’s a less useful trait when we lose sight of the big picture, such as the fact that despite all of our knowledge and good will, everyone will die someday. The more I make friends with this fact, the more important it becomes to use my skills to work with patients, to make the quality of their lives better, not just extend it as long as possible.

When the older man dies, you write that you tell him “rest well.” Do most doctors and nurses have rituals or acts of comfort in the face of death? If so, can you give a few examples?

I don’t know of many. When hospital chaplains are present, this sometimes helps medical professionals feel a bit more comfortable in ritualizing the death. Often everyone tries to act very professional, which is sometimes interpreted as being aloof or detached. A great deal depends on the relationship with the patient and family, as well. The reaction and process will be different for someone that was a long-time patient, versus someone that was met during the course of a hospital call.

There’s a lot of talk lately about how doctors are choosing to die. Should we be looking at doctors’ personal choices to guide our own?

We’re just as good at denial as the next person! I’ve had conversations with colleagues after a particularly difficult code, and we say we all would like to have “DNR” (do not resuscitate) tattooed on our chests when the time comes, so that there is no confusion about it. But until you are really faced with your own medical illness, when it’s personal and not work-related, I don’t think that younger physicians do much more planning ahead than others. Even though we work with the eventuality of death every day, I think it still remains a theoretical concept on a personal level, at least for those of us in the midst of parenting and careers and figuring out how to balance day-to-day life.

There are lots of conflicting emotions in your piece: you’re compassionate but your notes and demeanor must be clinical; you see both sadness and relief in people’s deaths. What is it about death that causes these opposites to intersect?

There are plenty of conflicting emotions in the practice of medicine. Living and dying are messy processes—beautiful, but messy. I’ve felt this intersection in other experiences in medicine—attending the birth of a healthy baby to a drug-addicted mom; holding the hand of the anxious woman who finally decided to leave her abusive husband; listening to the first hopeful words of the stoic man who found his girlfriend dead of a drug overdose. Death probably brings out this intersection of conflicting emotions more than anything. There is, of course, almost always an element of sadness because there is a process of letting go. But the letting go also allows the process of healing to begin, and there is a sense of relief and hope in that.

On a lighter note, can you share an uplifting moment you’ve had in the hospital recently?

My own work has shifted to be primarily focused on the practice of outpatient clinical medicine, directing the clinic in which I work, and quality improvement efforts. My uplifting moments come from walking with patients through the joys and challenges of their lives, and celebrating the things we are able to accomplish together to make their lives more satisfying and healthy. I find satisfaction in working to keep people out of the hospital. But of course, there is always that 100% statistic to deal with … so when illness and death come, as they always do, eventually, I walk with them on that journey, too. It really is an amazing privilege.

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Robyn Jodlowski is an editorial assistant at Creative Nonfiction and a recent graduate of the University of Pittsburgh’s nonfiction MFA program. She tweets @RoJoOhNo.

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